Tell Your Patients to Drink Up

Sometimes overlooked in the world of surgery, particularly in the faster pace and turnover of the outpatient setting, is the need to prepare patients' bodies for the physical demands of an operation. After all, even the least invasive of surgeries and mildest of anesthetics inflict some degree of trauma or distress on the patient's body. On some level, great or small, surgery's a shock to the system.

Rejecting the time-honored "fast after midnight" approach, a growing number of doctors, industry organizations and experts believe that more rigorous and thoughtful pre-op nutrition — lasting from weeks before to just 2 hours before surgery — can help bodies not only accommodate the stresses of surgery, but heal faster, too. Here's a look at the latest science behind pre-op nutrition, as well as a roundup of beverages (see "A Bounty of Pre-op Nutrition Drinks" here).

David Evans, MD, is not only the medical director of trauma services at The Ohio State University Wexner Medical Center, but he's also its medical director of nutrition services, and a widely cited expert on surgical nutrition. The co-author of a December 2013 paper, "Nutrition Optimization Prior to Surgery" (osmag.net/bQ6VYp), published in the American Society for Parenteral and Enteral Nutrition's (ASPEN) journal Nutrition in Critical Practice, he's representative of the evolving views on this subject. The first sentence of that paper's abstract captures his overall perspective: "Optimization of metabolic state prior to major surgery leads to improved surgical outcomes."

"You want to make sure that the immune system is well-fed, well-nourished and robust and able to heal the wound and fight off any potential infection," Dr. Evans tells Outpatient Surgery. To do that, your patient's nutrition levels should be at or near their peak. Especially needed are protein stores, the amino acids that build them, and the vitamins and minerals — like Vitamins C and B12 and zinc — that serve as cofactors and as the fuel for cells to heal, he says.

But how do you know how much pre-op nutrition a specific patient requires? Before admitting the patient, you should perform a nutrition screening, says Dr. Evans. Since many outpatient procedures are "lower-risk operations, there's probably not as much of a nutritional assessment intervention required" as with typical inpatient surgeries, says Dr. Evans. But as a growing number of outpatient centers are performing more complex procedures, a more rigorous pre-op nutritional assessment is more important in those cases. However, Dr. Evans stresses that nutrition screening should always be employed for "risk stratification, to decide who is appropriate for the ambulatory setting."

Patients who display undernutrition should be of particular concern, he says, but often such patients are waved through when maybe they shouldn't be, because they don't seem otherwise unhealthy. "Sometimes you may have someone who doesn't have the typical comorbidities that would flag them for ASA IIIs and IVs, but on a nutrition assessment — if you're looking at recent weight loss, or BMI less than 18.5 — if they meet one of those triggers, then they probably have some unrecognized nutritional risk," notes Dr. Evans. Another screening test, he says, can involve measuring serum albumin levels, with less than a 2.0 measure of the vital protein as a cutoff.

If those findings or others result in a diagnosis of undernutrition, Dr. Evans advises getting a dietitian involved. At the very least, he says, explore ways to optimize the patient's nutritional status before surgery.

Carb-loading

Patients with low BMI or recent weight loss should start supplementing protein and optimizing nutrition a month or more before surgery or, alternatively, surgery should be delayed until they can complete such a regimen, says Dr. Evans. When supplementing protein, he adds, "you may want to combine that with an exercise regimen, because to use protein most effectively, and to store it, you need to exercise so you can build muscle."

As the day of the procedure approaches, you can employ other methods. Studies have shown that supplements containing arginine and fish oil are beneficial with administration for a 5-day duration before surgery, says Dr. Evans.

Loading up on carbohydrates is also key for pre-op nutrition, says Dr. Evans. "Going through major surgery is no different, really, than putting your body through an intense athletic event," he explains. "So carbohydrate-loading is a strategy that's really emerged for pre-operative optimization of patients. Giving the patient extra sugars pre-op basically improves their insulin sensitivity, reduces thirst and hunger both pre-op and post-op, improves hydration in the perioperative setting, and has been linked to downstream improvement and outcomes.

"Now, we can't say, "Okay, eat some pasta 2 hours before surgery' because of the aspiration risk," he notes. But a moderate amount of nutritious clear liquids will do the trick. Multiple manufacturers offer complex carbohydrate drinks that are like liquid starch, containing formulae of vitamins, minerals, electrolytes, sugars, amino and Omega 3 fatty acids, and more. Dr. Evans says studies have shown that carb-loading strategies where the patient is given one dose of a drink 8 hours before surgery and another dose 2 hours before surgery work well. Most patients who consume these drinks are still able to empty their stomachs adequately before surgery. Bonus: The patient isn't starving and dehydrated — and thus probably not as cranky, moody or anxious — going into surgery.

Dr. Evans notes, however, that these drinks can be expensive and that insurers "generally" don't pay for them. He says many inpatient hospitals are paying for the drinks out of their own budgets and giving them to patients at no cost.

From fasting to fed

Pre-op nutrition promotes quicker bowel recovery and hospital discharge, and improves surgical outcomes, immune function and wound healing, Dr. Evans's co-authored study found, by promoting "attenuation of the metabolic response to stress." It's also widely claimed that pre-op nutrition can reduce readmissions.

There is a growing movement in medicine that echoes and expands on Dr. Evans's findings, and seeks to shine a brighter light on pre-op nutrition as part of a revised approach to the entire surgical process that produces more positive outcomes. The enhanced recovery after surgery (ERAS) concept has led to the founding of The ERAS Society in Europe in 2010, and the subsequent 2014 founding of the American Society for Enhanced Recovery (ASER). While these organizations focus mostly on perioperative protocols and research, they also solidly view pre-op nutrition as a vital component of post-operative recovery and health.

Carbohydrate-loading is a strategy that's really emerged for pre-op optimization of patients.

For example, ASER founding member Tong Joo Gan, MD, MHS, FRCA, professor and chairman of the Department of Anesthesiology at SUNY at Stony Brook, co-authored a March 2016 paper, "Preoperative Nutrition and Prehabilitation" (osmag.net/JpxE3D), for the Anesthesiology Clinics journal that said "identifying nutritionally deficient patients lets pre-op intervention optimize their nutritional status." A December 2015 paper by Elles Steenhagen, RD, of University Medical Center Utrecht (Netherlands), published in Nutrition in Clinical Practice and provocatively titled "Enhanced Recovery After Surgery: It's Time to Change Practice!" (osmag.net/eyMFN7), flatly states that "traditional practices such as prolonged pre-operative fasting (nil by mouth from midnight), bowel cleaning and reintroduction of oral nutrition 3-5 days after surgery are being shunned." Touting optimization of pre-op nutrition, she concludes, "As they challenge traditional surgical doctrine, the implementation of ERAS guidelines has been slow, despite the significant body of evidence indicating that ERAS guidelines may lead to improved outcomes."

Indeed, one of the more polarizing views on pre-op nutrition involves the hours immediately leading up to surgery. Fasting up to 12 hours before surgery has been standard practice for many decades as necessary for preventing complications from the administration of anesthesia, such as aspiration and PONV. But it's not without its own risks, and, as a result, perspectives on immediate pre-operative fasting are changing in some quarters.

For example, another ASPEN study from January 2006, published in its Journal of Parenteral and Enteral Nutrition, "A Carbohydrate"Rich Beverage Prior to Surgery Prevents Surgery" Induced Immunodepression: A Randomized, Controlled, Clinical Trial" (osmag.net/Rv7APx), found that fasting before surgery can actually induce post-operative insulin resistance, which is related to infectious morbidity. The authors found that pre-operative intake of a clear carbohydrate-rich beverage could counteract that insulin resistance.

The emerging ERAS pre-op nutrition ideas are being accepted and codified by many influential, traditional industry groups. For example, the American Association of Nurse Anesthetists (AANA) recognizes ERAS as a "clinical practice resource" (osmag.net/FpQJ3d), with the recommendation of a light meal (such as toast and clear liquids) up to 6 hours pre-op, and a carbohydrate beverage up to 2 hours pre-op. The American Society of Anesthesiologists (ASA) concurs (osmag.net/3jKMYf). The American College of Surgeons (ACS) promotes pre-op nutrition strategies as part of its multifaceted Strong for Surgery (S4S) pre-surgery patient health optimization program (osmag.net/ZHj9qF).

While this new pre-op nutrition consensus is building in the research and academic communities, many hospitals and surgical centers — either out of resistance or ignorance — still haven't adopted these new approaches. But by bulking up on protein, carbs, vitamins, minerals and acids — all the way up until 2 hours before surgery — your patients could have shorter recoveries and better outcomes. OSM

Patients with low BMI or recent weight loss should start supplementing protein and optimizing nutrition a month or more before surgery or, alternatively, surgery should be delayed until they can complete such a regimen, says Dr. Evans. When supplementing protein, he adds, "you may want to combine that with an exercise regimen, because to use protein most effectively, and to store it, you need to exercise so you can build muscle."

As the day of the procedure approaches, you can employ other methods. Studies have shown that supplements containing arginine and fish oil are beneficial with administration for a 5-day duration before surgery, says Dr. Evans.

Loading up on carbohydrates is also key for pre-op nutrition, says Dr. Evans. "Going through major surgery is no different, really, than putting your body through an intense athletic event," he explains. "So carbohydrate-loading is a strategy that's really emerged for pre-operative optimization of patients. Giving the patient extra sugars pre-op basically improves their insulin sensitivity, reduces thirst and hunger both pre-op and post-op, improves hydration in the perioperative setting, and has been linked to downstream improvement and outcomes.

"Now, we can't say, "Okay, eat some pasta 2 hours before surgery' because of the aspiration risk," he notes. But a moderate amount of nutritious clear liquids will do the trick. Multiple manufacturers offer complex carbohydrate drinks that are like liquid starch, containing formulae of vitamins, minerals, electrolytes, sugars, amino and Omega 3 fatty acids, and more. Dr. Evans says studies have shown that carb-loading strategies where the patient is given one dose of a drink 8 hours before surgery and another dose 2 hours before surgery work well. Most patients who consume these drinks are still able to empty their stomachs adequately before surgery. Bonus: The patient isn't starving and dehydrated — and thus probably not as cranky, moody or anxious — going into surgery.

Dr. Evans notes, however, that these drinks can be expensive and that insurers "generally" don't pay for them. He says many inpatient hospitals are paying for the drinks out of their own budgets and giving them to patients at no cost.

Pre-op nutrition promotes quicker bowel recovery and hospital discharge, and improves surgical outcomes, immune function and wound healing, Dr. Evans's co-authored study found, by promoting "attenuation of the metabolic response to stress." It's also widely claimed that pre-op nutrition can reduce readmissions.

There is a growing movement in medicine that echoes and expands on Dr. Evans's findings, and seeks to shine a brighter light on pre-op nutrition as part of a revised approach to the entire surgical process that produces more positive outcomes. The enhanced recovery after surgery (ERAS) concept has led to the founding of The ERAS Society in Europe in 2010, and the subsequent 2014 founding of the American Society for Enhanced Recovery (ASER). While these organizations focus mostly on perioperative protocols and research, they also solidly view pre-op nutrition as a vital component of post-operative recovery and health.

Carbohydrate-loading is a strategy that's really emerged for pre-op optimization of patients.

For example, ASER founding member Tong Joo Gan, MD, MHS, FRCA, professor and chairman of the Department of Anesthesiology at SUNY at Stony Brook, co-authored a March 2016 paper, "Preoperative Nutrition and Prehabilitation" (osmag.net/JpxE3D), for the Anesthesiology Clinics journal that said "identifying nutritionally deficient patients lets pre-op intervention optimize their nutritional status." A December 2015 paper by Elles Steenhagen, RD, of University Medical Center Utrecht (Netherlands), published in Nutrition in Clinical Practice and provocatively titled "Enhanced Recovery After Surgery: It's Time to Change Practice!" (osmag.net/eyMFN7), flatly states that "traditional practices such as prolonged pre-operative fasting (nil by mouth from midnight), bowel cleaning and reintroduction of oral nutrition 3-5 days after surgery are being shunned." Touting optimization of pre-op nutrition, she concludes, "As they challenge traditional surgical doctrine, the implementation of ERAS guidelines has been slow, despite the significant body of evidence indicating that ERAS guidelines may lead to improved outcomes."